This section contains general advice. It is for interest and as a point of discussion to be had with your own doctor.
Mr Knight is a doctor, but he is NOT YOUR doctor. (Unless you have actually consulted with him in person)
If you read and act on any information contained below you do so at your own risk. Before acting on any advice you should obtain a personalised assessment of your situation.
The internet can provide you all the information required to build a house but it doesn't make you a builder. Same with medicine!
"Dr Google" is not a doctor and you should not be your own doctor.
Exercise and Back Pain
Firstly let's put to rest a common misconception: “Exercise will wear out my joints and back.”
This is just NOT true.
Exercise is very simply the process of using muscles, heart, lungs and circulatory system to a level beyond simple base-line function.
Exercise is always good for you, there are NO exceptions.
Exercise is good for depression:
Exercise is good for hip/knee/hand arthritis
Exercise is good for CHRONIC low back pain (Chronic means more than 3 months)
The level of exercise, and type of exercise should be consistent with your general health, age, and capabilities. This is common sense.
Sometimes you might need help in establishing what those levels are. Your physiotherapist, personal trainer, or GP can help you with this.
If you are very frail and have established heart disease or lung disease, you might even need to see your heart or lung specialist to determine what level you should exercise at.
This doesn't change the fact that, Exercise is ALWAYS good for you.
There is a lot of discussion as to which is the " BEST " type of exercise.
It turns out no one knows. Everyone has their favourite, especially when they are making money. What that means is there is no best exercise.
Whole Body Exercise is the best type of exercise
If everybody did 20 minutes of whole body exercise every day, then there would be almost no obesity and no diabetes in our community. There would be less depression, less pain, and everyone would be happier. We would need far fewer doctors as we currently have.
So with such great outcomes, and no dangerous side effects, why isn't everyone doing it?
This is largely due to factors: Lack of knowledge and lack of motivation. (or Fear and Laziness if you like)
Maybe it's hard to do?
No, it's not.
So let's make it easy.
Exercise has to be 5 things if you are going to make it a regular feature of your life.
1. Exercise is something you can do.
No point recommending bike riding if you cannot ride a bike
2. Exercise is something you will do.
No point recommending swimming if you don't like the water.
3. Exercise is something you can afford
A personal trainer three times a week is expensive
Walking briskly is cheap.
4. Exercise is something that changes enough not to get you bored.
Doing the same thing every day is very dull - mix it up
5. Exercise is something social, so others support you to continue.
Having someone make you feel guilty about slacking off will keep you going.
There is no right or wrong exercise.
But there might be the wrong exercise for you, or the wrong exercise for you today.
However you are the only one who will know this. So it is trial and error. No one can look at your X-ray or MRI and tell you what the "right" exercise is.
Try something, if it hurts too much, try something else. Come back to the original thing when you are stronger and fitter.
Walking the dog briskly for twenty minutes can be exercise. Walking around the shopping centre before the shops open. Going for a swim at the beach or pool. Riding an exercise bike, or even a real bike. Walking on a treadmill, or cross-trainer. Planking. Using rubber bands. Doing squats. Lifting weights.
Exercise is simple. It is walking, riding, swimming, cycling, climbing, rowing, running, lifting, bending, stretching, Yoga, Tai Chi, Pilates or any other movement that uses your body.
So what makes it exercise?
You have to do it. Nobody can exercise you.
You must set aside 20 minutes per day, specifically for this pursuit. Going to work is rarely exercise.
Exercise develops. You must keep a diary, or a mental note of your performance, and you need to work to improve it.
Exercise is stressful, but in a good way. You must get your heart rate up, get a little sweaty, and a little short of breath. That makes it exercise. If you need to have a shower afterward, then you have exercised. If you could go out to dinner without changing your clothes afterward, then you haven't exercised.
Clearly everyone is different.
A 20 year old athlete will be able to get her pulse to 190, and swim 1.5km in 20 minutes.
A 85 year old grandmother after spine surgery will be able to get her pulse to 85, and swim 5 laps of the hydrotherapy pool.
Both people have exercised.
Exercise is always hard work to start.
You cannot exercise pain away.
Most exercise will INCREASE your pain initially.
If you are in severe pain, then wait.
You have to wait until your pain is manageable before you start. If you cannot get your pain to a manageable level then you need to see a pain management specialist.
Once your pain is manageable then you need to start exercising very slowly within your limits of pain.
That might mean walking up and down the corridor of your house for 5 minutes. It might mean two (2) squats. It might mean riding a bike for one (1 ) minute. You have to keep your pain manageable at all times, but you have to slowly increase your level of activity.
If you get sore, but the pain passes and you can repeat your exercise the next day, then that is about the right amount of exercise. If you are so sore you cannot get out of bed the next day, then you done too much. If you don't feel anything - work harder.
Exercise means setting aside time, and we are all busy.
It means being uncomfortable.
It may mean being in some pain.
It may mean being embarrassed by lack of performance.
At the beginning of football season even athletes hurt when the start exercising. However they only push themselves to the point of being sore that night. The next day pain is manageable and they start again. As we get older we need longer intervals of rest between bouts of exercise. 80 year old athletes (yes they exist) often only train three days a week.
After spinal surgery, or after recovering from your sore back you need to push yourself only so hard as to be sore for one day. If you are sore for a week then you have done too much. If you have to take substantially increase your medication then you have done too much.
Remember that being in pain does NOT mean you have damaged yourself. Even after surgery.
Most exercise pain that people feel is the body adjusting and strengthening itself. It should be accepted as desirable. You are making yourself stronger.
(You are only getting this hand-out from me because we have excluded dangerous type of pain. Your pain comes from an ageing body or recovering body, not from anything more serious.
Its too hot..... then go to an air-conditioned shopping mall before the shops open and walk around there.
Its too cold.... see above
It's too wet... see above.
I can't drive to the mall..... then go with a friend, because they need exercise too.
I live in the country and we don't have malls.... .....then walk around your house. Open up the doors, devise a route and turn up the radio to keep you company.
I get bored.....sure we all get bored. Change your exercise type, or location, or listen to music, or talk back radio.
I get too sore too quickly.... then take some over the counter simple pain medication one hour before exercising.
I get to sore afterward.. then keep taking regular simple pain killers until you get fitter. It is far safer to take regular paracetamol and exercise than to do nothing.
If you have to taker stronger pain killers then you are doing too much and you need to talk to me. Sometimes this is OK, particularly if you are recovering from surgery, but I need to be involved in this.
Focal Strengthening Exercise.
The best known of these exercises are the “ Core Strengthening Exercises” .
This is where you isolate a group of muscles and focus on strengthening just these muscles, with the aim of making them stronger.
This type of exercise might seem "easier" or more "targeted" or more "scientific"
The problem with Focal Strengthening Exercise is that it requires you to learn a program, and then stick with the program. It usually requires the supervision of a Physiotherapist, or Personal Trainer. So it takes the exercise out of your control and gives it to someone else.
These exercises can certainly be over-done. They can leave you very sore for days or weeks. I had a patient who thought he had appendicitis because he over did his Core Strengthening.
There are some very simple tummy flattening core exercises that you can do all the time.
More sophisticated focal exercise really should be done with your physio.
Which exercise is the best?
There are no right or wrong exercises. The good exercises are those that you like, those you can do, and those that don't hurt too much. Bad exercise is the type that puts you off exercising.
Muscle bulk and strength are the key. You don't have to look like a body builder, but the stronger your muscles and the more muscle you have, the healthier you will be.
If you still have questions, or if you want to discuss any of this in more detail then make another appointment to see me.
This information is of a general nature, and if you are not sure that you are well enough to exercise, then make sure you talk to your GP. Dr Michael Knight does not accept any responsibility or liability for illness or accident that occurs as a result of using this information in an irresponsible or thoughtless manner. This information is only for the person named at the top of the letter. If that isn't you, then get your own advice, because while I am a doctor, I am NOT YOUR DOCTOR.
This section discusses management of Chronic Degenerative Back Pain
Without nerve or spinal cord compression, or other structural failure, where there is no risk of tumour, infection, no history of trauma, or underlying metabolic condition.
This is the commonest type of back pain. It is where we really don't know what is causing the pain, but the pain is felt in the back.
As with all orthopaedic conditions there are three options for the management of low back pain:
Option 1. Do nothing. This is a painful condition, yet it is not a dangerous condition. There is no evidence of infection, neoplasm, fracture or spinal instability. There is no underlying neurological condition. Left untreated this condition will not, of itself, shorten life, or impair neurological functioning. The pain experienced is out of proportion to the underlying structural degeneration. This is always the case in degeneration in this part of the body. Pain is not an indication of further damage. It is an indication that a worn part of the body is protesting at being used. Ignoring the pain, and getting on with life, as if there was not a problem, is an option for some patients.
However pain itself can be a destructive force. It can cause depression, social isolation, and activity avoidance, that can lead to obesity, muscle atrophy and poor posture, that actually worsens the pain over time, as well as impacting other aspects of whole body health. For this reason most patient should treat their pain.
Option 2. Treat the pain non-procedurally.
Non-procedural pain management follows a bio-psycho-social model of health care.
The biological is using medicines and physical retraining to help with pain, but without short term injection therapy. Exercise has been shown to be more effective than any other intervention for low back pain in every age group.
The psychological is using insight, education, acceptance and treating psychological pathology, such as depression where necessary to help pain.
The social is investigating where a pain impaired patient sits in the community. The type of work that available to them, and provides a realistic assessment of their current physical capacity.
This is not done well by many practitioners. It is done very poorly by surgeons, and I do not offer this service.
A service that offers multimodal biopsychosocial pain management, is what you want
Rehabilitation physicians and sports medicine physician are the best option for this type of care.
Option 3. Procedural Therapy (Surgery and Injections)
Many pain management services focus on short term expensive procedural therapies, that might help for a few weeks or even months, but do not provide long-term benefit.
Chronic pain is a life-time problem, and needs life long solutions, no injections provide this.
Having said that injections of steroid into the spine can certainly help some situations. (I shall not discuss epidurals or nerve root injections here. These are for neurocompressive conditions. This section does not discuss neurocompressive condition).
Steroid acts as a high dose, intermediate acting anti-inflammatory and analgesic. As steroid works on the nucleus of the cell body, it will have an effect that outlasts the pharmacokinetic activity of the injection. For this reason steroids seem to work for months in some patients, and only days in others.
Injections cannot be repeated too often as they cause local and systemic alterations to multiple systems, including worsening of diabetes, increasing infection risk, and local destruction of connective tissue. There is no clear evidence to how many injections can be given in a 12 month period, but it would seem unwise to repeat joint injections more often than every 3 months.
Injection are usually delivered by radiological guidance, and this means most injection also incur a radiation dose that is cumulative. It also increases the cost.
There is no value in injecting the disc itself. There is no evidence that any disc injection helps. There is no gel, foam, or other injectable material that can restore the disc. Everything you can imagine has been tried, everything tired has failed.
Only the facet joints and sacro-iliac joints can be treated with injections.
The other type of injections are RadioFrequency Neurotomies (RFN), or RadioFrequency Denervation (RFD) they different names for the same thing. This combines steroid injection with a needle placed next to the innervation of the joint. The pain fibres are heated to greater than 55 degrees. This coagulates the protein in the C-fibres, without destroying the nerves. This works as a long acting anaesthetic. The nerves will resynthesize the protein, or rebuild the C-fibres, or otherwise rechannel pain through other neural tissue. For this reason RFN only works for an intermittent period of time. It will eventually fail. It can be repeated, but each repeat is less effective than the original.
Surgery for back pain, as the only diagnosis, is a low yield exercise. It is expensive in terms of time, and money, and patient resources, and only works well about 25% of the time. This is a last resort option for only a few patients. It is not funded by Medicare. I almost never do this operation.
Surgery for back pain is spinal fusion or a disc replacement.
Disc replacement for lumbar back pain is no better than fusion, and has potentially more significant downsides than fusion.
Disc replacement for cervical (neck) pain may well be better than fusion, but this is still being evaluated.
Spinal fusion means stopping the painful joints from moving and shifting the movement to other joints. These other joints will have to work harder, and will fail earlier as a result of the fusion. This has to be understood.
Surgery fails because we do not have a reliable way of knowing which is the painful joint. Selective anaesthetic injections and discography are considered by some to be helpful, but they are unreliable in all randomised trials. Therefore surgeons rely on the correlation of radiological degeneration with pain. It is not a reliable 1:1 correlation. Therefore very often a degenerative, but painless joint gets fused, leaving the painful "normal looking" joint to work harder, actually increasing the patient's pain. This is why sometimes after spinal fusion surgery patients actually get worse.
Patients with any of: established hyper-aesthetic chronic pain syndromes, compensation claims, smoking, psychiatric illness including depression, diabetes, obesity and osteoporosis tend to do far worse when have spinal fusion for back pain.
I have provided the following advice on Exercise and Back Pain.